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Chapter 4
1.
Copyright © 2011
Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 4 The Patient Record: Hospital, Physician Office, and Alternate Health Care Settings
2.
Copyright © 2011
Delmar, Cengage Learning. ALL RIGHTS RESERVED. Definition of Purpose of the Patient Record • Ownership of the patient record • Hospital inpatient record • Hospital outpatient record • Physician office record
3.
Copyright © 2011
Delmar, Cengage Learning. ALL RIGHTS RESERVED. Provider Documentation Responsibilities • Authentication of patient record entries – Signatures – Countersignatures – Initials – Fax signatures – Rubber stamp signatures – Abbreviations used in the patient record – Timeliness of patient record entries – Amending the patient record
4.
Copyright © 2011
Delmar, Cengage Learning. ALL RIGHTS RESERVED. Signature Stamp
5.
Copyright © 2011
Delmar, Cengage Learning. ALL RIGHTS RESERVED. Abbreviation List
6.
Copyright © 2011
Delmar, Cengage Learning. ALL RIGHTS RESERVED. Development of the Patient Record • Date order of patient record reports • Outpatient record: handling repeat visits • Physician office record: continuity of care
7.
Copyright © 2011
Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Record Formats • Primary and secondary sources of information • Source-oriented record (SOR) • Problem-oriented record (POR) • Integrated record
8.
Copyright © 2011
Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Record Formats (Continued) • Automated record systems • Computers in health care • Longitudinal patient record • Advantages and disadvantages of manual and automated record systems
9.
Copyright © 2011
Delmar, Cengage Learning. ALL RIGHTS RESERVED. Archived Records • Record retention laws • Alternative storage methods • Facility retention policy considerations • Off-site storage
10.
Copyright © 2011
Delmar, Cengage Learning. ALL RIGHTS RESERVED. Patient Record Completion Responsibility • Governing board and facility administration • Attending physicians and other health care professionals
11.
Copyright © 2011
Delmar, Cengage Learning. ALL RIGHTS RESERVED. Role of the HIM Department in Record Completion • Record assembly • Quantitative analysis • Qualitative analysis • Concurrent analysis • Statistical analysis